Daratumumab, bortezomib, thalidomide and dexamethasone (DVTD)

DVTD is the name of a cancer drug combination. It includes the drugs we list below, next to each drug we have how you pronounce the drug name in brackets.

• D - daratumumab (dar-rah-too-moo-mab), this is also known as Darzalex

• V - bortezomib (bor-tez-oh-mib), this is also known as Velcade

• T - thalidomide (tha-lid-oh-mide)

• D - dexamethasone (deks-ah-meth-uh-zone) - this is a steroid

It is a treatment for people with myeloma who are able to have an autologous stem cell transplant .

How does DVTD work?

Daratumumab is a type of targeted cancer drug called a monoclonal antibody (MAB). It works by targeting a certain protein (called CD38) on myeloma cells so your immune system  can recognise them. The immune system can then attack and kill the myeloma cells. 

Bortezomib and thalidomide are types of targeted cancer drugs.

Bortezomib is a proteasome inhibitor. Proteasomes are in cells. They help to break down proteins that the cell doesn't need. Bortezomib blocks the proteasomes, so the proteins build up inside the cell. The cell then dies.

Thalidomide works in different ways. It: 

• stops cancer cells developing

• stops cancers making their own blood vessels which they need to be able to grow

• stimulates some of the immune system cells to attack myeloma cells

Dexamethasone is a steroid. It helps bortezomib and thalidomide to work better and kills myeloma cells.

How do you have DVTD?

You usually have daratumumab as an injection under the skin. In some situations, you might have it as a drip into a vein (intravenously). You have bortezomib as an injection under your skin. You take thalidomide as capsules and dexamethasone as tablets.

Injection just under the skin

You usually have injections under the skin (subcutaneous injection) into the stomach, thigh or top of your arm.

You might have stinging or a dull ache for a short time after this type of injection but they don't usually hurt much. The skin in the area may go red and itchy for a while.

As a drip into your vein

You have this through a thin short tube (a cannula) that goes into a vein in your arm. You have a new cannula each time you have treatment.

Taking your tablets or capsules

You should take the right dose, not more or less.

Talk to your healthcare team before you stop taking a cancer drug, or if you have missed a dose.

You should take dexamethasone tablets after a meal or with milk as they can irritate your stomach. Taking them in the morning might help to stop difficulty in sleeping (insomnia).

You usually take your thalidomide capsules at bedtime. This helps you to feel less sleepy at other times of the day.

How often do you have DVTD?

You have DVTD as cycles of treatment. This means that you have the drugs and then a rest to allow your body to recover.

Each cycle of DVTD lasts 4 weeks (28 days). You have a total of 6 cycles. You have cycles 1 to 4 and then have an autologous stem cell transplant. After the transplant you then have cycles 5 and 6.

Below is an example of one way of having DVTD. In this example you have bortezomib twice a week. Some people may have bortezomib once a week.

For cycles 1 and 2

You have daratumumab as an injection under your skin on days 1, 8, 15 and 22 of your cycle.

You have bortezomib as an injection under your skin on days 1, 4, 8 and 11 of your cycle (twice weekly).

You take dexamethasone as tablets on days 1,2,8,9,15,16, 22 and 23 of your cycle.

You take thalidomide as capsules at night before bed every day from day 1 to day 28 of your cycle.

You then start your next cycle of treatment.

For cycles 3,4,5 and 6

You have daratumumab as an injection under your skin on days 1 and 15 of your cycle.

You have bortezomib as an injection under your skin on days 1, 4, 8 and 11 of your cycle (twice weekly).

You take dexamethasone as tablets on days 1,2,8,9,15 and 16 of your cycle.

You take thalidomide as capsules at night before bed every day from day 1 to day 28 of your cycle.

You then start your next cycle of treatment.

Tests

You have blood tests before and during your treatment. They check your levels of blood cells and other substances in the blood. They also check how well your liver and kidneys are working.

Before treatment starts you have a blood test to check for viruses such as hepatitis B, hepatitis C, HIV or cytomegalovirus (CMV) . This is called a viral screen. You may not know if you have one or more of these viruses. But it is important for your doctor to know as this treatment can weaken your immune system .

What are the side effects of DVTD?

Side effects can vary from person to person. They also depend on what other treatments you're having. 

When to contact your team

Your doctor, nurse or pharmacist will go through the possible side effects. They will monitor you during treatment and check how you are at your appointments. Contact your advice line as soon as possible if:

• you have severe side effects 

• your side effects aren’t getting any better

• your side effects are getting worse

Early treatment can help manage side effects better. 

We haven't listed all the side effects here. Remember it is very unlikely that you will have all of these side effects. But you might have some of them at the same time.

Common side effects

These side effects happen in more than 10 in 100 people (more than 10%). You might have one or more of them. They include:

Increased risk of getting an infection

Increased risk of getting an infection is due to a drop in white blood cells. Symptoms include a change in temperature, aching muscles, headaches, feeling cold and shivery and generally unwell. You might have other symptoms depending on where the infection is.

Infections can sometimes be life threatening. You should contact your advice line urgently if you think you have an infection. 

Bruising, bleeding gums or nosebleeds

This is due to a drop in the number of platelets in your blood. These blood cells help the blood to clot when we cut ourselves. You may have nosebleeds or bleeding gums after brushing your teeth. Or you may have lots of tiny red spots or bruises on your arms or legs (known as petechiae).

Blood clots

Blood clots can develop in the deep veins of your body, usually the leg. This is called deep vein thrombosis (DVT). A blood clot can be very serious if it travels to your lungs (pulmonary embolism), although this isn’t common.

Symptoms of a blood clot include:

•    pain, redness and swelling around the area where the clot is and may feel warm to touch
•    breathlessness
•    pain in your chest or upper back – dial 999 if you have chest pain
•    coughing up blood

Numbness or tingling in fingers or toes

Numbness or tingling in fingers or toes is often temporary and can improve after you finish treatment. Tell your healthcare team if you're finding it difficult to walk or complete fiddly tasks such as doing up buttons. 

You might also notice you have less feeling in your fingers or toes. Or you may have strange sensations such as pins and needles.

Constipation

Constipation is easier to sort out if you treat it early. Drink plenty and eat as much fresh fruit and vegetables as you can. Try to take gentle exercise, such as walking. Tell your healthcare team if you think you are constipated. They can give you a laxative if needed.

Tiredness and weakness (fatigue)

Tiredness and weakness (fatigue) can happen during and after treatment. Doing gentle exercises each day can keep your energy up. Don't push yourself, rest when you start to feel tired and ask others for help.

Fluid build up

You may have swelling of your hands and legs due to a build up of fluid (oedema). You might also have swelling in other parts of the body.

Feeling sick

Feeling sick is usually well controlled with anti sickness medicines. Avoiding fatty or fried foods, try eating small meals and snacks, drinking plenty of water, and relaxation techniques can all help.

It is important to take anti sickness medicines as prescribed even if you don’t feel sick. It is easier to prevent sickness rather than treat it once it has started.

High temperature (fever)

Tell your healthcare team straightaway if you get a high temperature. Ask them if you can take paracetamol to help lower your temperature.

Numbness or tingling

You might have unusual skin sensations such as numbness, tingling, prickling or burning. It can feel like pins and needles. 

Let your doctor or nurse know if you have this.

Sore mouth and throat

It may be painful to swallow drinks or food. Painkillers and mouth washes can help to reduce the soreness and keep your mouth healthy. 

Allergic reaction

It's very common to have a reaction to daratumumab. It's most likely to happen on the day of treatment but symptoms of an allergic reaction can appear up to 4 days after having daratumumab.

Your nurse will check you regularly. Symptoms include fever, chills, chest pain, rash, vomiting, facial swelling or difficulty breathing. You have a steroid tablet called dexamethasone before and after to try to prevent a reaction.

Less commonly you might have an allergic reaction to one of the other drugs.

Tell your nurse straight away if you feel unwell while you have this treatment and for a time afterwards.

Low levels of calcium in the blood

Low calcium levels in the blood can cause painful muscle spasms, cramps or muscle twitching. You might also get numbness or tingling in your feet, hands or around your mouth.

Tremor

This treatment can make you tremble or shake (tremor). Talk to your team if you have notice this happening.

Confusion, anxiety or agitation

You may have some confusion, feel worried (anxious) or more agitated and restless. You may also feel very low in mood (depressed).

Talk to your healthcare team if you or your loved ones notice this.

Weakness of the arms and legs

You might have some weakness of your arms and legs. Tell your healthcare team if this happens.

Dizziness or feeling light headed

These drugs might make you feel dizzy or light headed. Don’t drive or operate machinery if you have this.

Lower level of consciousness

You might be more drowsy or less aware of what is happening around you. If your loved ones or anyone caring for you notice this they should contact your healthcare team straight away.

Weight changes

Talk to your team if you are gaining or losing weight.

Loss of appetite

You might lose your appetite for various reasons while having cancer treatment. Sickness, taste changes or tiredness can put you off food and drinks.

Dry mouth

A dry mouth is also called xerostomia (pronounced zero-stow-mee-a). Talk to your healthcare team if you have this. They can give you artificial saliva to help with a dry mouth. It can also help to drink plenty of fluids.

Pain in the muscles or joints

You might have pain in your muscles or joints. Speak to your healthcare team about what painkillers can help.

Shortness of breath

Tell your nurse or call the advice line if you feel short of breath. This could be for different reasons, including a sign of infection (pneumonia) or blood clot. They can find the cause and help treat it.

Dial 999 or go to A& E immediately if you are finding it difficult to breathe.

Skin problems

Skin problems include a skin rash, dry skin or peeling skin. This usually goes back to normal when your treatment finishes. Your healthcare team can tell you what products you can use on your skin to help.

Liver changes

You might have liver changes that are usually mild and unlikely to cause symptoms. They usually go back to normal when treatment finishes. You have regular blood tests to check for any changes in the way your liver is working.

Indigestion or heartburn

Contact your doctor or pharmacist if you have indigestion or heartburn. They can prescribe medicines to help.

High blood sugar levels

This treatment can make your blood sugars go up. You have regular blood and urine tests to check this. If you have diabetes you may need to check your blood sugar levels more often than usual. 

Problems with sleeping

Thalidomide can make you feel more sleepy. Dexamethasone can make it harder to sleep.

Try and take your thalidomide tablets in the evening and dexamethasone in the morning. This can help your sleep.

Occasional side effects

These side effects happen in between 1 and 10 out of every 100 people (between 1 and 10%). You might have one or more of them. They include:

• a second cancer
• low potassium levels in the blood
• fainting
• a stroke
• heart problems such as an irregular or fast heart rate or reduced blood flow to the heart
• feeling like things are moving or spinning around you (vertigo)

Rare side effects

Infection with hepatitis B can become active again if you've had it in the past. This side effects happens in fewer than 1 in 100 people (less than 1%).

Other side effects

If you have side effects that aren't listed on this page, you can look at the individual drug pages:

• daratumumab
• bortezomib
• thalidomide
• steroids

We also have information on bortezomib, thalidomide and dexamethasone (VTD) including possible side effects.

We have more information about side effects and tips on how to cope with them.

What else do you need to know?

Other medicines, foods and drinks

Cancer drugs can interact with medicines, herbal products, and some food and drinks. We are unable to list all the possible interactions that may happen. An example is grapefruit or grapefruit juice which can increase the side effects of certain drugs.

Tell your healthcare team about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies. Also let them know about any other medical conditions or allergies you may have.

Pregnancy and contraception

This treatment may harm a baby developing in the womb. It is important not to become pregnant for at least 4 weeks before your treatment, while you’re having treatment and for 3 months afterwards.

Women of childbearing age must use reliable contraception for at least 4 weeks before the start of treatment, while you are having treatment and at least 3 months after treatment. This includes breaks in between cycles of treatment. You will have a pregnancy test before and every 4 weeks during treatment. You will also have one 4 weeks after finishing your treatment.

Men taking thalidomide need to use a condom during treatment and for 3 months after if:

• their partner is pregnant
• their partner is able to become pregnant and their partner is not using effective contraception.

This also applies to men who have undergone sterilisation (vasectomy), because thalidomide is passed into semen.

Your doctor will ask you to sign a consent form. This is to confirm you understand the information given about thalidomide and the risks to a developing baby.

Handling of thalidomide

Some people worry about taking thalidomide, but it does not cause physical defects in adults. Pregnant women and children should not touch or handle thalidomide. You must store it in a place children cannot reach it.

Loss of fertility

You may not be able to become pregnant or get someone pregnant after treatment with these drugs. Talk to your doctor before starting treatment if you think you may want to have a baby in the future.

Men might be able to store sperm before starting treatment. And women might be able to store eggs or ovarian tissue. But these services are not available in every hospital, so you would need to ask your doctor about this.    

Breastfeeding

Don’t breastfeed during this treatment. This is because the drugs may come through in your breast milk.

Treatment for other conditions 

If you are having tests or treatment for anything else, always mention your cancer treatment. For example, if you are visiting your dentist.

Immunisations

Don’t have immunisations with live vaccines while you’re having treatment and for up to 12 months afterwards. The length of time depends on the treatment you are having. Ask your doctor or pharmacist how long you should avoid live vaccinations.

In the UK, live vaccines include rubella, mumps, measles, BCG, yellow fever and one of the shingles vaccines called Zostavax.

You can have:

• other vaccines, but they might not give you as much protection as usual
• the flu vaccine (as an injection)
• the coronavirus (COVID-19) vaccine - talk to your doctor or pharmacist about the best time to have it in relation to your cancer treatment

Members of your household who are aged 5 years or over are also able to have the COVID-19 vaccine. This is to help lower your risk of getting COVID-19 while having cancer treatment and until your immune system recovers from treatment.

Contact with others who have had immunisations - You can be in contact with other people who have had live vaccines as injections. Avoid close contact with people who have recently had live vaccines taken by mouth (oral vaccines) such as the oral typhoid vaccine. Sometimes people who have had the live shingles vaccine can get a shingles type rash. If this happens they should keep the area covered.

If your immune system is severely weakened, you should avoid contact with children who have had the flu vaccine as a nasal spray as this is a live vaccine. This is for 2 weeks following their vaccination.

Babies have the live rotavirus vaccine. The virus is in the baby’s poo for about 2 weeks and could make you ill if your immunity is low. Get someone else to change their nappies during this time if you can. If this isn't possible, wash your hands well after changing their nappy.

More information

For further information about each drug and the possible side effects go to the electronic Medicines Compendium (eMC) website. You can find patient information leaflets for each drug on this website.

You can report any side effect you have to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.